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17 Pediatric Conditions, 395

18 Psychiatric Conditions, 424

Appendix A Food Sources for Selected Nutrients, 441

8
Copyright

3251 Riverport Lane

St. Louis, Missouri 63043

PRACTICE GUIDELINES FOR FAMILY NURSE PRACTITIONERS, FOURTH

EDITION
ISBN: 978-0-323-29080-7

Copyright © 2016, 2014, 2004 by Elsevier

All rights reserved. No part of this publication may be reproduced or transmitted in

any form or by any means, electronic or mechanical, including photocopying,
recording, or any information storage and retrieval system, without permission in
writing from the publisher. Details on how to seek permission, further information
about the Publisher’s permissions policies and our arrangements with organizations
such as the Copyright Clearance Center and the Copyright Licensing Agency, can be
found at our website: www.elsevier.com/permissions.

This book and the individual contributions contained in it are protected under
copyright by the Publisher (other than as may be noted herein).

Notices
Knowledge and best practice in this field are constantly changing. As new research
and experience broaden our understanding, changes in research methods,
professional practices, or medical treatment may become necessary.
Practitioners and researchers must always rely on their own experience and
knowledge in evaluating and using any information, methods, compounds, or
experiments described herein. In using such information or methods they should be
mindful of their own safety and the safety of others, including parties for whom

9
they have a professional responsibility.
With respect to any drug or pharmaceutical products identified, readers are
advised to check the most current information provided (i) on procedures featured
or (ii) by the manufacturer of each product to be administered, to verify the
recommended dose or formula, the method and duration of administration, and
contraindications. It is the responsibility of practitioners, relying on their own
experience and knowledge of their patients, to make diagnoses, to determine
dosages and the best treatment for each individual patient, and to take all
appropriate safety precautions.
To the fullest extent of the law, neither the Publisher nor the authors,
contributors, or editors, assume any liability for any injury and/or damage to
persons or property as a matter of products liability, negligence or otherwise, or
from any use or operation of any methods, products, instructions, or ideas
contained in the material herein.

Previous editions copyrighted 2014 (revised), 2004, 2000, 1997

Library of Congress Cataloging-in-Publication Data

Fenstermacher, Karen, author.
Practice guidelines for family nurse practitioners/Karen Fenstermacher, Barbara
Toni
Hudson.—.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-0-323-29080-7 (spiral bound: alk. Paper)
I. Hudson, Barbara Toni, author. II. Title.
[DNLM: 1. Nurse Practitioners. 2. Family Nursing—methods. WY 128]
RT120.F34
610.73—dc23 2013020571

Executive Content Strategist: Lee Henderson

Associate Content Development Specialist: Samantha Dalton
Publishing Services Manager: Julie Eddy
Project Manager: Jan Waters
Designer: Brian Salisbury

Printed in the United States of America

Last digit is the print number: 9 8 7 6 5 4 3 2 1

10
11
Reviewers
Sameeya Ahmed-Winston, RN, MSN, CPNP, CPHON Pediatric Nurse Practitioner,
Children’s National Medical Center, Washington, D.C.
Margaret-Ann Carno, PhD, MBA, RN, CPNP, D, ABSM, FAAN Associate Professor
of Clinical Nursing and Pediatrics, School of Nursing, University of Rochester,
Rochester, New York
Robin Webb Corbett, PhD, FNP-C, RNC Associate Professor, East Carolina
University College of Nursing, Greenville, North Carolina
Laura Crisanti, MSN, CCRN, CPNP-PC/AC Pediatric Nurse Practitioner, Ann &
Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
William Mark Enlow, DNP, ACNP, CRNA, DCC Assistant Professor, Columbia
University School of Nursing, New York, New York
Mary A. Blaszko Helming, PhD, APRN, FNP-BC, AHN-BC Professor of Nursing,
Quinnipiac University School of Nursing, Hamden, Connecticut
Kathleen Sanders Jordan, DNP, MS, RN, FNP-BC, SANE-P Nurse
Practitioner/Lecturer, School of Nursing, Mid-Atlantic Emergency Medical
Associates and the University of North Carolina at Charlotte, Charlotte, North
Carolina
Kari Ksar, RN, MS, CPNP Pediatric Nurse Practitioner, Lucile Packard Children’s
Hospital, Palo Alto, California
Suzanne Kujawa, RNC, MSN, CPNP-PC Pediatric Nurse Practitioner, Ann &
Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
Kelley S. Madick, MSN, CNP, DNPc Faculty, Kaplan University, Davenport, Iowa
Jessica A. Pech, APN, MSN, CPNP Pediatric Nurse Practitioner, Ann & Robert H.
Lurie Children’s Hospital of Chicago, Chicago, Illinois
Caroline A. Rich, RN, MSN, CPNP-AC/PC Pediatric Nurse Practitioner Pediatric
Neurology, Helen DeVos Children’s Hospital, Grand Rapids, Michigan
Jill Harpst Rodgers, DNP, CRNP, MSN, RN Assistant Professor of Graduate
Nursing, Carlow University, Pittsburgh, Pennsylvania

12
Dr. Michelle Taylor Skipper, DNP, FNP-BC Clinical Associate Professor, East
Carolina University College of Nursing, Greenville, North Carolina
Laura Steadman, Ed.D, CRNP, MSN, RN Assistant Professor, University of
Alabama at Birmingham, Birmingham, Alabama

13
Preface
Karen Fenstermacher, Barbara Toni Hudson

Practice Guidelines for Family Nurse Practitioners is a quick reference book for
practicing and student nurse practitioners in a variety of disciplines. Although not
intended as a textbook, it is an excellent resource, providing protocols for treatment
options for patients of varied ages in varied settings.
For ease of use, Unit I contains chapters about complete and detailed histories and
physical examinations of adult, pediatric, and geriatric patients. Specialized physical
examinations are included (e.g., sports). Chapters are written in an easy-to-read and
accessible format according to body systems. Common diseases are covered,
including signs and symptoms, diagnostic methods, drug therapies, and treatment
and adjunctive therapies. Some conditions (e.g., cognitive impairment, anemia, and
diabetes) have been expanded. Updated national standard guidelines are used
where available (e.g., asthma, diabetes, lipid treatment, Pap smears).
Special chapters include geriatric evaluation, pediatrics, and psychiatric
conditions. There is also a section on the care of wounds resulting from vascular
disease or peripheral pressure. The Appendix provides information about dietary
sources of different nutrients. Pain management guidelines have been expanded.

14
Acknowledgments
My thanks first to God, without whose help I would not be where I am now. Also,
thank you to Tammy (the nurse I have worked with for 20 years!) and Karrie; you
both make my job much easier and I wouldn’t want to do it without you.
Karen

My thanks go to my family, David and Cody, for all their support, encouragement,
and understanding for all the lost time. I cannot forget my faithful friends, Kim,
Lynda, and Ann for their hours of help with reading and re-reading the chapters.
Toni

We are (and have been) very blessed to have many collegial relationships with
physicians, nurse practitioners, and physician assistants who we work with, consult
with, and refer to—too many to name individually, but we thank you all! We also
are blessed to have the trust of the patients we see, and we have learned much from
them.
Karen and Toni

We also want to thank the people at Elsevier for all their help; our book would not
be what it is without their input.

15
UNIT I

History and Physical

Examination
OUTLINE

1. Adult assessment

2. Pediatric assessment

3. Geriatric assessment

4. Laboratory and diagnostic pearls

16
CHAPTER 1

Adult assessment
Guideline for integrated, comprehensive
physical examination*
History
I. Biographic information (e.g., “facesheet information”)

II. Chief complaint (CC)

A. State in the patient’s own words

B. Note if the patient’s actions agree with or contradict the stated

CC

III. History of the present illness (HPI)

A. Try to present a clear account of the patient’s CC, including

what treatments have been tried before (what worked and
what did not)

B. Question the patient regarding the following:

1. Onset (e.g., when, where)

2. Characteristics (e.g., description of the quality of discomfort,

radiation, associated symptoms such as N/V)

3. Course (e.g., length of the event, alleviating or aggravating

factors)

17
 4. What does the patient think is wrong?

C. Also note pertinent negative responses (e.g., absence of cough

or fever)

IV. Past medical history (PMH)

A. This tells the nurse practitioner when to be more concerned

(e.g., someone with an essentially negative PMH is not as
worrisome as a patient with heart disease or an underlying
chronic illness)

B. Question the patient regarding significant childhood and adult

illnesses, surgeries, and hospitalizations, including emergency
department visits

C. Ask about current medications and treatments, including OTC

preparations, OCs, inhalers, eye drops, herbal supplements or
vitamins, and customs (e.g., home remedies, cultural
treatments)

D. Ask about the immunization status, including influenza,

pneumococcal vaccines (Pneumovax 23 and Prevnar 13),
shingles vaccine, and TB test

E. Ask whether the patient has reactions (e.g., allergies,

sensitivities) to any medicine and what occurs when the
medicine is taken (common side effects such as nausea are
often perceived as an allergy)

F. Ask about street drug, alcohol, and tobacco use (specific types,
amounts, and routes)

V. Family history (FH)

A. FH is important for the identification of risk factors; gather

information about grandparents, parents, and siblings

18
 B. Focus on cardiovascular disease, DM, cancer, PVD, seizure
disorders, asthma, and psychiatric disorders

C. The phrase “significant FH” indicates that several family

members from different generations have had a specific disease

VI. Psychosocial history

A. Living situation, including significant other in life

B. Dietary and rest patterns

C. Types and frequency of exercise

D. Occupation

E. Spiritual assessment

1. Faith or beliefs

2. Importance and influence in the patient’s life

3. Involvement in a religious/spiritual community and is this a

support to the patient

VII. Review of systems (ROS): offers the chance to systematically investigate various
body systems to obtain any additional information that would be helpful in arriving
at an accurate diagnosis

VIII. Recording the history: record historical data in the above sequence,
remembering to include pertinent positive and negative responses and pertinent
past laboratory data.

Physical examination
I. General appearance (e.g., grooming and dressing, facial expressions, symmetry of
movement) and skin color and turgor

A. Appears acutely ill

19
 B. Signs of dehydration (e.g., dry mucous membranes,
tachycardia, dizziness)

C. Cyanosis or pallor

D. SOB or use of accessory muscles to breathe

E. Drooling (epiglottitis; see Chapter 17)

II. Vital signs: temperature, pulse, respiration, BP (including postural VS with

dizziness or syncope), weight, height, and BMI

A. Postural VS changes: initially determine the VS with the

patient lying quietly; next have the patient sit (and then stand,
if indicated) and within 2 to 5 minutes of position change(s),
recheck the VS. With postural changes, one or more of the
following will happen:

1. ≥20 mmHg drop in systolic BP

2. ≥10 mmHg drop in diastolic BP

3. Patient becomes symptomatic (e.g., dizzy)

B. A low diastolic BP (<65 mmHg) implies decreased peripheral

resistance or aortic valve regurgitation (which is significant,
even if the heart sounds are not loud)

III. Inspect the skin

A. Fingernail clubbing

B. Suspicious or unusual lesions

IV. Head, ears, eyes, nose, and throat (HEENT)

A. Inspect the face and head

B. Palpate the scalp, temporal area for pulsation, and masseter

20
 muscles (have the patient clench his or her teeth)

C. Eyes

1. Check for the best visual acuity: right eye, left eye, and both
eyes (note with/without corrective lenses)

a) distance (e.g., Snellen chart)

b) newsprint (document how far away it is held to read, e.g., 6

inches)

c) counting fingers

d) hand motion

e) light perception

f) no light perception

2. Check for pupil reactivity: shine light first in the unaffected eye
(both pupils should constrict) and then in the affected eye; if
pupils dilate, the optic nerve in the affected eye is not working
(see Marcus Gunn pupil, Table 1-3)

3. Pressure: gently press on closed eyes for symmetry

4. Peripheral visual fields: sit/stand at eye level directly in front of

the patient to check peripheral field vision

5. Alignment

a) have the patient look straight ahead toward the light—the light
reflection should be symmetrical

b) test extraocular muscles (EOMs)

c) nystagmus

21
6. External: observe lid symmetry

7. Anterior: examine the conjunctiva, sclera, and cornea

a) red eye or drainage

8. Perform ophthalmoscopy, if possible; refer if dilated

examination is needed

D. Ears

1. Palpate the auricle and tragus

2. Perform otoscopy (Figure 1-1)

a) redness, bulging, perforation, retraction, or decreased mobility

of TM

b) bullae on TM (mycoplasma infection)

c) pain on palpation of the auricle or tragus

3. Administer appropriate hearing tests: Weber’s test, Rinne test

(Figure 1-2), and 2- to 3-foot whisper

4. If the patient is hard of hearing, ask the patient to hum

a) conductive defect: hum is louder in the affected ear

b) sensorineural defect: hum is louder in the unaffected ear

E. Nose: examine the nasal septum and nares for mucosal color,
polyps, perforations, and presence of swelling

F. Oropharynx: inspect the lips, gums, teeth, tongue, buccal

mucosa, uvula, and pharynx

1. Determine the “grade” of tonsils

22
 1+: barely extend beyond the tonsillar pillars

2+: extend halfway to the uvula

3+: touch the uvula

4+: tonsils touch each other

a) peritonsillar abscess

b) exudative pharyngitis

c) palatine petechiae

d) postnasal drainage

2. Determine the presence of partial plates, full dentures, caries, if

any

G. Palpation

1. Over sinuses (e.g., over maxillofrontal areas, mastoids, C2) for

pain or pressure

2. Neck

a) lymphadenopathy with or without tenderness (Figure 1-3)

b) thyroid abnormalities

V. Respiratory

A. Observe the chest for AP and lateral diameter and deformities

B. Auscultate the anterior and posterior chest and right lateral

chest (Figure 1-4)

1. Rales: fine, crackle sounds that can be associated with fluid in

the airways or with fibrosis

23
 2. Rhonchi: coarser sounds, as with someone who needs to cough;
often clears with cough

3. Stridor: high-pitched inspiratory sound associated with

laryngeal spasm

4. Wheeze: low-pitched inspiratory or expiratory sound

associated with bronchospasm or pulmonary congestion

C. Examine the chest, including respiratory excursion, and

perform bronchophony, egophony, and whispered
pectoriloquy, if indicated

D. Percuss posterior lung fields

1. Dullness indicates consolidation (e.g., pneumonia, pleural

effusion)

2. Hyperresonance (consider emphysema or pneumothorax)

E. Percuss diaphragmatic excursion and palpate for vocal

fremitus, if indicated

F. Examine capillary refill in the nailbeds

1. Capillary refill >3 seconds

VI. Chest/Cardiovascular

A. Palpate the precordium

1. Thrills, heaves (left ventricular [LV] dysfunction: apical; right

ventricular [RV] or left atrial [LA] dysfunction: parasternal), or
lifts

2. Displacement of PMI

B. Inspect breasts for skin redness, dimpling, or puckering;

24
 specifically, inspect while the woman (1) places her hands on
her hips and shrugs her shoulders and (2) presses her palms
together over her head

C. Palpate breasts and axillary, supraclavicular, and epitrochlear

nodes (with the patient in the supine position)

1. Abnormal skin changes

2. Nodules or lymphadenopathy

3. Nipple discharge

4. Supraclavicular nodes

D. Auscultation (Figure 1-5)

1. Listen over the precordium with the patient seated upright and
leaning forward, in the supine position, and in the left lateral
position

2. Use both the bell and the diaphragm

3. Listen for S1 and S2 (including splits); to identify S1, time it with

the carotid pulse

a) split S1 is usually normal; best heard in the tricuspid area

b) split S2 is physiologic (normal) if it resolves with deep

expiration (i.e., it is “blown away”)

c) paradoxical split S2: consider left bundle branch block (LBBB)

or aortic stenosis

d) fixed split S2: consider atrial septal defect

e) murmurs (also see murmurs in Chapter 8 and Table 8-1)

25
Another random document with
no related content on Scribd:
roar as it plunged over the bluff and tore a way down to the rocks
below. The slide gathered momentum as it went.
Hollister peered down. The crouched figure was gone, had been
buried in the giant billow of white.
The engineer refastened his ski, took a few swinging strokes
forward, and came to a smooth incline. Down this he coasted rapidly.
The buried man was just struggling out of the white mass when a
hand closed on his coat collar. It dragged him from the pack and held
him firmly down. Not till Tug made sure that the revolver was missing
did he let the man rise.
“Wot’ell’s eatin’ youse?” the rescued man growled, snarling at him.
Tug Hollister stood face to face with the tramp he knew by the name
of Cig. Recognition was simultaneous.
“What were you doing at my camp?”
“Aw, go chase yoreself. I ain’t been near your camp.”
“All right, if that’s your story. We’ll go back there now. The sheriff
wants you.”
The evil face of the crook worked. Out of the corner of his twisted
mouth he spoke venomously. “Say, if I had my gun I’d croak youse.”
“But you haven’t it. Get busy. Dig out your skis.”
“Nothin’ doing. Dig ’em yoreself if youse want ’em.”
Hollister knew of only one argument that would be effective with this
product of New York’s underworld. He used it, filled with disgust
because circumstances forced his hand. When Cig could endure no
longer, he gave way sullenly.
“’Nuff. But some day I’ll get you right for this. I aimed to bump you
off, anyhow. Now I soitainly will. I ain’t forgot you rapped on me to
that guy Reed.”
“I’ve told you once I didn’t, and you wouldn’t believe me. We’ll let it
go at that. Now get those skis.”
The snowshoes were rescued and the broken one mended. Hollister
watched his prisoner every minute of the time. He did not intend to
run the risk of being hit in the head by a bit of broken rock.
The two moved down into the valley, Cig breaking trail. He made
excuses that he was dead tired and couldn’t go another step. They
did not serve him well. His captor would not let the crook get in his
rear for a single second. He knew that, if the fellow got a chance, he
would murder him without the least hesitation.
In a blinding snowstorm the two men reached camp. Twice Cig had
tried to bolt and twice had been caught and punished. This was a
degrading business, but the engineer had no choice. It was
necessary to bring the man in because he had been up to some
deviltry, and Hollister could not let him go without first finding out
what it was.
He took him into his own tent and put him through a searching quiz.
The result of it was precisely nothing. Cig jeered at him defiantly. If
he could prove anything against him, let him go to it. That was the
substance of the New Yorker’s answers.
“All right. I’ll turn you over to Clint Reed. He’s got something to say to
you for stealing his little girl. From the way he talked, I judge you’re
in for a bad time of it.”
Cig protested. He hadn’t stolen the girl. How did they know he had?
Who said so? What would he do a crazy thing like that for? To all of
which Hollister said calmly that he would have to explain that to
Reed. If he could satisfy the cattleman, it would be all right with him.
Reed could pass him on to Sheriff Daniels without further delay.
“You’re a heluva pardner, ain’t youse?” sneered the crook with an
ugly lift of his upper lip. “T’row me down foist chance youse get.”
“I’m not your partner. We hit different trails the day we left the
Diamond Bar K ranch. You needn’t play baby on me. That won’t buy
you anything.”
“Gonna turn me over to Reed, then, are youse?”
“I’ve no time to bother with you. He’ll know how to handle the case.
Better that way, I reckon.”
Cig said nothing. For half an hour there was silence in the tent.
Hollister knew that his threat was sinking in, that the kidnapper was
uneasily examining the situation to find the best way out.
Daylight came, and with it signs of activity around the camp. Smoke
poured out of the stovepipe projecting from the chuck tent. Men’s
voices sounded. At last the beating of an iron on the triangle
summoned them to breakfast.
“We’ll eat before we start,” Hollister said.
“Don’ want nothin’ to eat,” growled the prisoner.
“Different here. I do. You’ll come along, anyhow.”
The men at breakfast looked with surprise at the guest of the boss
when he appeared. Hollister explained what he was doing there.
“I want to go into the tunnel and have a look around before any of
you do any work,” he added. “This fellow was up to some mischief,
and I want to find out what it was.”
Cig’s palate went dry. He knew better than they did in what a
predicament he had put himself. If he let the thing go through as
originally intended, these men would never let him reach a sheriff. If
he confessed—what would they do to him?
He ate mechanically and yet voraciously, for the exercise of the night
had left him hungry. But every moment his mind was sifting the facts
of the case for an out.
Hollister rose to leave. “Take care of this fellow till I get back, Tom. I
don’t know what he was up to, but if anything happens to me, rush
him right down to Daniels.”
“We will—in a pig’s eye,” the foreman answered bluntly. “If anything
happens to you, we’ll give this bird his, muy pronto.”
The engineer was lifting the flap of the tent when Cig spoke huskily
from a parched throat. “I’ll go along wid youse.”
“All right.” Not the least change of expression in his face showed that
Hollister knew he had won, knew he had broken down the fellow’s
stiff and sullen resistance.
Cig shuffled beside Tug to the tunnel. The months had made a
difference in the bearing of the ex-service man. When the New
Yorker had met him first, Hollister’s mental attitude found expression
in the way he walked. He was a tramp, in clothes, in spirit, in habit of
life, and in the way he carried his body. The shoulders drooped, the
feet dragged, the expression of the face was cynical. Since then
there had been relit in him the spark of self-respect. He was a new
man.
He stepped aside, to let Cig pass first into the tunnel. At the entrance
he lit two candles and handed one to his prisoner.
“What did you want to come for?” he asked. “Have you something to
show me? Or something to tell me?”
Cig moved forward. He spoke over his shoulder, protecting the
candle with one hand. “Just a bit of a lark. Thought I’d throw a scare
into yore men.”
“How?”
The former convict continued through the tunnel to the face of the
rock wall. He set his candle down on a niche of jutting sandstone.
With his fingers he scraped away some sand from the ragged wall.
“What’s that?” Hollister’s voice was sharp. He held out his hand.
“Let’s have it.”
From beneath the sand Cig had taken a stick of dynamite. He dug up
five others.
The object of putting them there was plain enough. If a workman had
struck any one of them with a pick, there would have been an
explosion, and the sand beds round the rocks were precisely the
places into which the pick points would have gone. The thing had
been a deliberate attempt at cold-blooded wholesale murder.
“Sure you have them all?” Hollister asked.
“Yep. Had only six.” He added, with a whine: “Didn’t aim to hurt any
o’ the boys, but only to scare ’em some.”
The engineer made no comment. He drove his prisoner before him
back into the light. Tom met him at the entrance to the tunnel. The
foreman examined the sticks of dynamite, listened to what Hollister
had to say, and jerked his head toward Cig.
“The boys’ll fix him right so’s he’ll never pull another trick like this,”
he told his chief.
“No,” opposed Hollister. “Nothing of that sort, Tom. I’m going to take
him down to the sheriff. We’ll send him over the road.”
“Like blazes we will!” the foreman burst out. “If you hadn’t happened
to see him this morning, three or four of us might be dead by now.
Hanging’s too good for this guy.”
“Yes,” agreed Tug. “But we’re not going to put ourselves in the wrong
because he is. The law will deal with him.”
“The boys ain’t liable to feel that way,” Tom said significantly.
“They won’t know anything about it till we’ve gone. You’ll tell them
then.” His hand fell on the foreman’s shoulder with a grip that was
almost affectionate. “We can’t have a lynching here, Tom. We’d be
the ones in bad then.”
Tom had to feel his way through a few moments of sulkiness to
acceptance of this point of view. “All right. You’re the doctor. Hustle
this fellow outa camp an’ I’ll wait till you’re gone. Sure he’s picked up
every stick of this stuff?”
Cig was quite sure about that. He spoke humbly and with all the
braggadocio gone from his manner. He had been thoroughly
frightened and did not yet feel wholly out of the woods. Not till he
was behind the bars would he feel quite safe again.
 CHAPTER XXIII
OUT OF THE BLIZZARD

Tom called a warning to Hollister as the engineer and his prisoner

struck out into the blinding storm. “Careful you don’t get lost. Looks
like she’s gettin’ her back up for a reg’lar snifter.”
The snow was still falling thickly, but it had behind it now a driving
wind that slapped it in the faces of the men at a slanting angle.
Presently under the lee of a hill they got their backs to the storm, but
this did not greatly improve conditions, for the whip of the wind
caught up the surface drifts and whirled them at the travelers.
Hollister had buckled on a belt with a revolver and had taken the
precaution to rope his prisoner to him with ten feet of slack between.
They ploughed through the new snow that had fallen above the
crust, making slow progress even with the wind to help.
From the shelter of the gulch they came into the full force of the
howling hurricane. It caught them as they crossed a mesa leading to
a cañon. Hollister realized that the snow was thinning, but the wind
was rising and the temperature falling. He did not like that. Even to
his lack of experience there was the feel of a blizzard in the air.
Moreover, before they were halfway across the mesa he had a
sense of having lost his direction.
Cig dropped back, whining. This was an adventure wholly out of his
line. He was game enough in his way, but bucking blizzards was not
one of the things he had known in his city-cramped experience.
“We gotta go back. It’ll get us sure if we don’t,” he pleaded.
Tug would have turned back gladly enough if he had known which
way to go, but in the swirl of white that enveloped them he did not
know east from west. The thing to do, he judged, was to strike as
straight a line as possible. This ought to take them off the mesa to
the shelter of some draw or wooded ravine.
“It’ll be better when we get where the wind can’t slam across the
open at us,” he said.
For the moment at least the former convict was innocuous. He was
wholly preoccupied with the battle against the storm. Tug took the
lead and broke trail.
The whirling snow stung his face like burning sand. His skis clogged
with the weight of the drifts. Each dragging step gave him the sense
of lifting a leaden ball chained to his feet.
Cig went down, whimpering. “I’m all in!” he shrieked through the
noise of the screaming blasts.
“Forget it, man!” Hollister dragged him to his feet. “If you quit now
you’re done for. Keep coming. We’ll get off this mesa soon. It can’t
be far now.”
He was none too confident himself. Stories came to his mind of men
who had wandered round and round in a circle till the blizzard had
taken toll of their vitality and claimed them for its own.
The prisoner sank down again and had to be dragged out of the drift
into which he had fallen. Five or six times the taut rope stopped
Tug’s progress. Somehow he cheered and bullied the worn-out man
to the edge of the mesa, down a sharp slope, and into the wind-
break of a young grove of pines.
Into the snow Cig dropped helplessly. The hinges of his knees
wouldn’t hold him any longer. His expression reminded Hollister of
the frightened face of a child.
“I’m goin’ west,” he said.
“Not this trip,” the engineer told him. “Buck up and we’ll make it fine.
Don’t know this country, do you? We’re at the mouth of a gulch.”
Cig looked around. In front of him was a twisted pine that looked like
an umbrella blown inside out. He recognized it.
“This gulch leads into another. There’s a cabin in it,” he said. “A
heluva long ways from here.”
“Then we’d better get started,” Tug suggested. “The cabin won’t
come to us.”
He gave the Bowery tough a hand to help him to his feet. Cig pulled
himself up.
“Never get there in the world,” he complained. “Tell you I’m done.”
He staggered into the drifts after his leader. The bitter wind and cold
searched through their clothing to freeze the life out of them. At the
end of a long slow two hundred yards, the weaker man quit.
Hollister came back to him. He lay huddled on the newly broken trail.
“Get up!” ordered Tug.
“Nothin’ doing. I’m through. Go on an’ leave me if youse want to, you
big stiff.”
It was the man’s last flare of defiance. He collapsed into himself,
helpless as a boxer counted out in the roped ring. Hollister tugged at
him, cuffed him, scolded, and encouraged. None of these seemed
even to reach his consciousness. He lay inert, even the will to live
beaten out of him.
In that moment, while Hollister stood there considering, buffeted by
the howling wind and the sting of the pelting sleet, he saw at his feet
a brother whose life must be saved and not an outlaw and potential
murderer. He could not leave Cig, even to save himself.
Tug’s teeth fastened to one end of a mitten. He dragged it from his
hand. Half-frozen fingers searched in his pocket for a knife and
found it. They could not open the blade, and he did this, too, with his
teeth. Then, dropping to one knee awkwardly, he sawed at the
thongs which fastened the other’s skis. They were coated with ice,
but he managed to sever them.
He picked up the supine body and ploughed forward up the gulch.
The hope he nursed was a cold and forlorn one. He did not know the
cañon or how far it was to the gulch in which the cabin was. By
mistake he might go wandering up a draw which led nowhere. Or he
might drop in his tracks from sheer exhaustion.
But he was a fighter. It was not in him to give up. He had to stagger
on, to crawl forward, to drag his burden after him when he could not
carry it. His teeth were set fast, clinched with the primal instinct to go
through with it as long as he could edge an inch toward his goal.
A gulch opened out of the cañon. Into it he turned, head down
against a wind that hit him like a wall. The air, thick with sifted ice,
intensely cold, sapped the warmth and vitality of his body. His
numbed legs doubled under the weight of him as though hinged. He
was down and up again and down, but the call of life still drove him.
Automatically he clung to his helpless load as though it were a part
of himself.
Out of the furious gray flurry a cabin detached itself. He weaved a
crooked path toward it, reached the wall, crept along the logs to a
door. Against this he plunged forward, reaching for the latch blindly.
The door gave, and he pitched to the floor.
He lay there, conscious, but with scarcely energy enough of mind or
body to register impressions. A fire roared up the chimney. He knew
that. Some one rose with an exclamation of amazement at his
intrusion. There was a hiatus of time. His companion of the
adventure, still tied to him, lay on the floor. A man was stooping over
Cig, busy with the removal of his ice-coated garments.
The man cut the rope. Hollister crawled closer to the fire. He
unfastened the slicker and flung it aside. If he had not lost his knife,
he would have cut the thongs of the skis. Instead, he thrust his feet
close to the red glow to thaw out the ice-knots that had gathered.
He was exhausted from the fight through the deep drifts, but he was
not physically in a bad way. A few hours’ sleep would be all he
needed to set him right.
“Take a nip of this,” a squeaky voice advised.
Hollister turned his head quickly. He looked into the leathery face
and skim-milk eyes of Jake Prowers. It would be hard to say which of
them was the more startled.
“By jiminy by jinks, if it ain’t the smart-aleck hobo engineer,” the
cattleman announced to himself.
“Is he alive?” asked Tug, nodding toward the man on the floor.
“Be all right in a li’l’ while. His eyes flickered when I gave him a drink.
How’d you come here, anyhow?”
“Got lost in the storm. He played out. Had to drag him.” Tug rubbed
his hands together to restore circulation.
“Mean you got lost an’ just happened in here?”
“Yes.”
“Hmp! Better be born lucky than with brains, I’ll say. What were you
doin’ out in the blizzard? Where you headed for?”
“I was taking him to Wild Horse—to the sheriff.”
A mask dropped over the eyes of the little cattleman. “What for?
What’s he been doin’?”
“He’s wanted for shooting Mr. Reed and firing his wheatfield.”
“You been appointed deputy sheriff since you took to playin’ good?”
“And for other things,” the engineer added, as though Prowers’s
sneer had not been uttered.
“Meanin’ which?”
“Kidnapping Reed’s little girl.”
“No proof of that a-tall. Anything more?”
The eyes of the two met and grew chill. Hollister knew that the
rancher was feeling out the ground. He wanted to find out what had
taken place to-day.
“What more could there be?” Tug asked quietly.
Neither relaxed the rigor of his gaze. In the light-blue orbs of the
older was an expression cold and cruel, almost unhuman,
indefinably menacing.
“Claims I was tryin’ to blow up his mine.” The voice came from
behind Prowers. It was faint and querulous. “Say, I’m froze up inside.
Gimme a drink, Jake.”
Prowers passed the bottle over. He continued to look at the uninvited
guest who knew too much. “Howcome you to get that notion about
him blowin’ up yore tunnel?” he asked.
“Caught him at it. Dragged him back and made him show where he
had put the sticks of powder,” Hollister answered grimly. “You
interested in this, Mr. Prowers?”
“Some. Why not? Got to be neighborly, haven’t I?” The high voice
had fallen to a soft purr. It came to Hollister, with a cold swift patter of
mice feet down his spine, that he was in deadly danger. Nobody
knew he was here, except these two men. Cig had only to give it out
that they had become separated in the blizzard. They could, unless
he was able to protect himself, murder him and dispose of the body
in entire safety. If reports were true, Prowers was an adept at that
kind of sinister business. Tug had, of course, a revolver, but he knew
that the cattleman could beat him to the draw whenever he chose.
The old man was a famous shot. He would take his time. He would
make sure before he struck. The blow would fall when his victim’s
wariness relaxed, at the moment when he was least expecting it.
Tug knew that neither of these two in the room with him had any
regard for the sanctity of human life. There are such people, a few
among many millions, essentially feral, untouched by any sense of
common kinship in the human race. Prowers would be moved by
one consideration only. Would it pay to obliterate him? The greatest
factor in the strength of the cattleman’s position was that men
regarded him with fear and awe. The disappearance of Hollister
would stir up whisperings and suspicions. Others would read the
obvious lesson. Daunted, they would sidestep the old man rather
than oppose him. Yet no proof could be found to establish definitely
a crime, or at any rate to connect him with it.
The issue of the Sweetwater Dam project meant more to Prowers
than dollars and cents. His power and influence in the neighborhood
were at stake, and it was for these that he lived. If the irrigation
project should be successful, it would bring about a change in the
character of the country. Settlers would pour in, farm the Flat Tops,
and gobble up the remnants of the open range. To the new phase of
cattle-raising that must develop, he was unalterably opposed. He
had no intention, if he could prevent it, of seeing Paradise Valley
dominated by other men and other ways. The development of the
land would make Clint Reed bulk larger in the county; it would
inevitably push Jake into the background and make of him a minor
figure.
To prevent this, Prowers would stick at nothing. Hollister was only a
subordinate, but his death would serve excellently to point a sinister
moral. If more important persons did not take warning, they, too,
might vanish from the paths of the living.
“You’re neighborly enough, even if you visited us by deputy this
morning,” Hollister answered, level gaze fixed on the cattleman.
“Did I visit you by deputy?” Jake asked, gently ironical.
“Didn’t you? One with six sticks of dynamite to help us on the job.”
“News to me. How about it, Cig? What’s yore smart-aleck friend
drivin’ at?”
Cig had crept forward to the fire and lay crouched on the hearth. His
twitching face registered the torture of a circulation beginning to
normalize itself again in frozen hands and feet.
“Said he’d turn me over to that guy Reed. Took advantage of me
while I was played out to beat me up,” snarled the city tough. He
finished with a string of vile epithets.
The splenetic laughter of the cattleman cackled out. “So you’re
aimin’ to take Cig here down to Daniels with that cock-an’-bull story
you cooked up. Is that the play?”
“Yes, I’m going to take him down—now or later.”
This appeared to amuse the little man. His cracked laughter sounded
again. “Now or later, by jimmy by jinks. My hobo friend, if you’d lived
in this country long as I have, you wouldn’t gamble heavy on that
‘later.’ If you’d read yore Bible proper, you’d know that man’s days
are as grass, which withers up considerable an’ sudden. Things
happen in this world of woe right onexpected.”
Tug did not dodge this covert threat. He dragged it into the open.
“What could happen to me now we’re safe out of the storm, Mr.
Prowers?”
The skim-milk eyes did not change expression, but there seemed to
lie back of them the jeer of mockery. “Why, ’most anything. We eat
canned tomatoes for supper, say—an’ you get lead poisonin’. I’ve
known real healthy-lookin’ folks fall asleep an’ never wake up.”
“Yes. That’s true,” Hollister agreed, an odd sinking in the pit of his
stomach. “And I’ve seen murderers who could have passed a first-
class life insurance examination quit living very suddenly. The other
day I read a piece about a scoundrel in Mexico who had killed two or
three people. He rather had the habit. When he shot another in the
back, his neighbors rode to his ranch one night and hanged him to
his own wagon tongue.”
“I always did say Mexico was no place for a white man to live,” the
old fellow piped amiably. “Well, I expect you boys are hungry, buckin’
this blizzard. What say to some dinner?”
“Good enough. No canned tomatoes, though, if you please.”
Once more Hollister and Prowers measured eyes before the
cattleman grinned evilly.
“Glad you mentioned it. I was aimin’ to have tomatoes,” he said.
 CHAPTER XXIV
“COME ON, YOU DAMN BUSHWHACKER”

The fury of the storm rattled the window panes. Down the chimney
came the shrill whistle of the gale. The light of day broke dimly
through the heavy clouds that swept above the gulch from peak to
peak.
Two of the men sitting at dinner in the cabin watched each other
intently if covertly. The third, dog-tired, nodded over the food he
rushed voraciously to his mouth.
“Gonna pound my ear,” Cig announced as soon as he had finished
eating.
He threw himself on a bunk and inside of five minutes was snoring.
Tug, too, wanted to sleep. The desire of it grew on him with the
passing hours. Overtaxed nature demanded a chance to recuperate.
Instead, the young man drank strong coffee.
Jake Prowers’s shrill little voice asked mildly, with the hint of a cackle
in it, if he was not tired.
“In the middle of the day?” answered Tug, stifling a yawn.
“Glad you ain’t. You ’n’ me’ll be comp’ny for each other. Storm’s
peterin’ out, looks like.”
“Yes,” agreed the guest.
It was. Except for occasional gusts, the wind had died away. Tug
considered the possibility of leaving before night fell. But if he left,
where could he go in the gathering darkness? Would Prowers let him
walk safely away? Or would a declaration of his intention to go bring
an immediate showdown? Even so, better fight the thing out now,
while he was awake and Cig asleep, than wait until he slipped into
drowsiness that would give the little spider-man his chance to strike
and kill.
Tug had no longer any doubt of his host’s intention. Under a thin
disguise he saw the horrible purpose riding every word and look. It
would be soon now. Why not choose his own time and try to get the
break of the draw?
He could not do it. Neither will nor muscles would respond to the
logical conviction of his mind that he was entitled to any advantage
he could get. To whip out his gun and fire might be fair. He had no
trouble in deciding that it was. But if luck were with him—if he came
out alive from the duel—how could he explain why he had shot down
without warning the man who was sheltering him from the blizzard?
For that matter, how could he justify it to himself in the years to
come? A moral certainty was not enough. He must wait until he
knew, until the old killer made that lightning move which would give
him just the vantage-ground Tug was denying himself.
All that Tug could do was watch him, every nerve keyed and muscle
tensed, or bring the struggle to immediate issue. He came, suddenly,
clearly, to the end of doubt.
“Time I was going,” he said, and his voice rang clear.
“Going where?” Prowers’s hand stopped caressing his unshaven
chin and fell, almost too casually, to his side.
They glared at each other, tense, crouched, eyes narrowed and
unwinking. Duels are fought and lost in that preliminary battle of
locked eyes which precedes the short, sharp stabbings of the
cartridge explosions. Soul searches soul for the temper of the foe’s
courage.
Neither gaze wavered. Each found the other stark, indomitable. The
odds were heavily in favor of the old cattleman. He was a practiced
gunman. Quicker than the eye could follow would come the upsweep
of his arm. He could fire from the hip without taking aim. Nobody in
the county could empty a revolver faster than he. But the younger
man had one advantage. He had disarranged Prowers’s plans by
taking the initiative, by forcing the killer’s hand. This was
unexpected. It disturbed Jake the least in the world. His opponents
usually dodged a crisis that would lead to conflict.
A cold blast beat into the house. In the open doorway stood a man,
the range rider Black. Both men stared at him silently. Each knew
that his coming had changed the conditions of the equation.
Under the blue cheek of the newcomer a quid of tobacco stood out.
It was impossible to tell from his impassive face how much or how
little of the situation he guessed.
“Ran outa smokin’,” he said. “Thought I’d drap over an’ have you
loan me the makin’s.”
He had closed the door. Now he shuffled forward to the fire and with
a charred stick knocked the snow from his webs.
“A sure enough rip-snorter, if any one asks you,” he continued mildly
by way of comment on the weather. “Don’t know as I recall any storm
wuss while it lasted. I seen longer ones, unless this ’un ’s jest
gatherin’ second wind.”
Tug drew a deep breath of relief and eased down. Red tragedy had
been hovering in the gathering shadows of the room. It was there no
longer. The blessed homely commonplace of life had entered with
the lank homesteader and his need of “the makin’s.”
“Not fur from my place,” Black went on, ignoring the silence. “But I’ll
be dawg-goned if it wasn’t ’most all I could do to break through the
drifts. If I’d ’a’ known it was so bad I’m blamed if I wouldn’t ’a’ stayed
right by my own fireside an’ read that book my sister give me twenty-
odd years ago. Its a right good book, I been told, an’ I been waitin’ till
I broke my laig to read it. Funny about that, too. The only time I ever
bust my laig an’ got stove up proper was ’way down on Wild Cat
Creek. The doc kep’ me flat on a bunk three weeks, an’ that book
‘David Coppermine’ a whole day away from me up in the hills.”
“David Copperfield,” suggested Tug.
“Tha’s right, too. But it sure fooled me when I looked into it onct. It
ain’t got a thing to do with the Butte mines or the Arizona ones
neither. Say, Jake, what about that tobacco? Can you lend me the
loan of a sack?”
Prowers pointed to a shelf above the table. He was annoyed at
Black. It was like his shiftlessness not to keep enough tobacco on
hand. Of all the hours in the year, why should he butt in at precisely
this one? He was confoundedly in the way. The cattleman knew that
he could not go on with this thing now. Don was not thoroughgoing
enough. He would do a good many things outside the law, but they
had to conform to his own peculiar code. He had joined in the cattle
stampede only after being persuaded that nobody would be hurt by
it. Since then Jake had not felt that he was dependable. The
homesteader was suffering from an attack of conscience.
Cig had wakened when the rush of cold air from the open door had
swept across the room. He sat up now, yawning and stretching
himself awake.
“What a Gawd-forsaken country!” he jeered. “Me for de bright lights
of li’l’ ol’ New York. If Cig ever lands in de Grand Central, he’ll stick
right on de island, b’lieve me. I wisht I was at Mike’s Place right dis
minute. A skoit hangs out dere who’s stuck on yours truly. Some
dame, I’ll tell de world.” And he launched into a disreputable
reminiscence.
Nobody echoed his laughter. Hollister was disgusted. Black did not
like the tramp. The brain of Prowers was already spinning a cobweb
of plots.
Cig looked round. What was the matter with these boobs, anyhow?
Didn’t they know a good story when they heard one?
“Say, wot’ell is dis—a Salvation Army dump before de music opens
up?” he asked, with an insulting lift of the upper lip.
Tug strapped on his skis, always with an eye on Prowers.
Which reminded Cig. A triumphant venom surged up in him.
“Gonna take me down to de cop, are youse?” he sneered. “Say, will
youse ring for a taxi, Jake? I gotta go to jail wid dis bird.”
In two sentences Prowers gave his version of the story to Black. Tug
corrected him instantly.
“He came to blow us up in the tunnel. When I took him back, he dug
six sticks of dynamite out of the dirt in the rock wall.”
Black spat into the fire. His face reflected disgust, but he said
nothing. What was there to say, except that his soul was sick of the
evil into which he was being dragged by the man he accepted as
leader?
Tug put on his slicker.
“Where you going?” asked Black.
“To the camp.”
“’S a long way. Better stay at my shack to-night.”
“Much obliged. I will.”
They went out together. Tug was careful to walk with Black between
him and the cabin as long as it was in sight.
The wind had died completely, so that the air was no longer a white
smother. Travel was easy, for the cold had crusted the top of the
snow. They worked their way out of the gulch, crossed an edge of
the forest reserve, and passed the cabin of the homesteader
Howard. Not far from this, Black turned into his own place.
The range rider kicked off his webs and replenished the fire. While
he made supper, Hollister sat on the floor before the glowing piñon
knots and dried his skis. When they were thoroughly dry, he waxed
them well, rubbing in the wax with a cork.
“Come an’ get it,” Black called presently.
They sat down to a meal of ham, potatoes, biscuits, plenty of gravy,
and coffee. Tug did himself well. He had worked hard enough in the
drifts to justify a man-size hunger.
Their talk rambled in the casual fashion of haphazard conversation.
It touched on Jake Prowers and Cig, rather sketchily, for Black did
not care to discuss the men with whom he was still allied, no matter
what his private opinion of them might be. It included the tunnel and
the chances of success of the Sweetwater Dam project, this last a
matter upon which they differed. Don had spent his life in the saddle.
He stuck doggedly to the contention that, since water will not run
uphill, the whole enterprise was “dawg-goned foolishness.”
Hollister gave up, shrugging his shoulders. “All right with me. A man
convinced against his will, you know. Trouble with you is that you
don’t want the Flat Tops irrigated, so you won’t let yourself believe
they can be.”
“The Government engineers said they couldn’t be watered, didn’t
they? Well, their say-so goes with me all right.”
“They were wrong, but you needn’t believe it till you see water in the
ditches on Flat Top.”
“I won’t.”
Tug rose from the table and expanded his lungs in a deep, luxurious
yawn. “Think I’ll turn in and sleep round the clock if you don’t mind. I
can hardly keep my eyes open.”
Black waved his hand at the nearest bunk. “Go to it.”
While he was taking off his boots, the engineer came to a matter he
wanted to get off his mind. “Expect you know the hole I was in when
you showed up this afternoon. I’ll say I never was more glad to see
anybody in my life.”
“What d’you mean?” asked Black, blank wall eyes full on his guest.
“I mean that Prowers was watching for a chance to kill me. I’d called
for a showdown a moment before you opened the door.”
The range rider lied, loyally. “Nothin’ to that a-tall. What would Jake
want to do that for? Would it get him anything if he did? You sure
fooled yoreself if that’s what you were thinking.”
“Did I?” The eyes of the younger man were on Black, hard, keen,
and intent. “Well, that’s exactly what I was thinking. And still am.
Subject number two on which we’ll have to agree to disagree.”
“Jake’s no bad man runnin’ around gunnin’ men for to see ’em kick.
You been readin’ too much Billy the Kid stuff, I shouldn’t wonder.”
Tug dropped the second boot on the floor and rose to take off his
coat.
There came the sound of a shot, the crash of breaking glass.
Hollister swayed drunkenly on his feet, groped for the back of a
chair, half turned, and slid to the floor beside the bunk.
Usually Black’s movements were slow. Now no panther could have
leaped for the lamp more swiftly. He blew out the light, crept along
the log wall to the window, reached out a hand cautiously, and drew
a curtain across the pane through which a bullet had just come.
Then, crouching, he ran across the room and took a rifle from the
deer’s horns upon which it rested.
“Come on, you damn bushwhacker. I’m ready for you,” he muttered.